‘Abstinence only’ approach to COVID failed in 2021 — missed opportunity for teaching harm reduction

Today, perusing the COVID-19 related headlines one would be forgiven for thinking it the dark days of late 2020 — and not the tail end of 2021. Exponential growth of cases, hospitals getting shored up with federal assets and the inability to test are all themes that ring familiar. Looking back over the past year, the question arises of what we actually learned to find ourselves facing some of the same problems a year ago.

Assuredly though — despite the similarities — December 2021 is incalculably different than December 2020. The COVID-19 vaccines and the 61 percent of the population that have been fully vaccinated assures us of a different trajectory as do monoclonal antibodies, antivirals, as well as rapid antigen tests (use them if you got them). The knowledge we have gained about the virus, its transmission and its epidemiology has also been decisive.

Nevertheless, looking back on the last 12 months of the COVID-19 pandemic, I am struck about how the opportunity to teach people and articulate a harm reduction strategy to cope with COVID-19 was missed over and over again.

This is evident in my own life as I field calls (sometimes multiple times per day) from friends about how to navigate a world in which COVID-19 is ever-present. Sometimes, people seem shocked to realize that COVID-19 has always been destined for endemicity, that there is no “zero COVID,” and that risk will never be able to be driven to zero if one wants to have any sort of social Interaction. In short, the post-pandemic world is not the world of 2019 but one in which COVID-19 is a virus we all incorporate into our daily risk calculations.

In recent days, this type of talk is very common coming on the heels of President Biden’s speech and updates to CDC isolation and quarantine guidance that very much concretize the endemicity of COVID-19. By articulating a sustainable and practicable scientifically informed path forward, these plans are part-and-parcel of a very successful public health policy known as harm reduction.

Rooted in the world of HIV, hepatitis C, sexually transmitted infection prevention, as well an injection drug use, harm reduction identifies the fact that individuals will take risks and providing them with guidance to modify risks has great value. Counseling abstinence fails and serves to drive risky behavior underground devoid of any attenuation.

Unlike the other infectious diseases, the approach to COVID-19 this past year (and stretching back to the early days of the pandemic) has been one consistent with an “abstinence-only” approach that eschewed any risk-taking. By promoting such an approach — that was not practicable by many — not only was behavior driven underground but the ability of the public to risk calculate was stunted.

Chastising joggers without masks, lamenting high passenger volumes on airplanes and scowling at Disneyland attendees, the advocates of abstinence jettisoned everything we learned about public health communication from decades of research and practice from the realm of harm reduction.

The divisiveness over the pandemic, I believe, takes some of its root in the abstinence-only approach and led to the false dichotomy the country has been mired in the past year: with some proportion of the population acting as if a pandemic is not taking place, while another segment cannot navigate a world in which any risk of COVID-19 is present.

This phenomenon has become more vivid in the criticisms being voiced over, what is being perceived as, an abrupt shift in the administration’s tone regarding COVID-19. For the abstinent, the change is jarring and likely the result of an expectation that getting back to normal would mean a world in which COVID-19 was no longer a presence or a fact of life.

It was evident almost from day 1 that COVID-19, caused by an efficiently spreading respiratory virus with an animal host, was with us for good. The goal of the public health campaign was not to somehow return the virus magically to bats but to tame the virus and shift its spectrum of illness to the mild side — all the while acknowledging that there would always be a baseline number of cases, hospitalizations and deaths.

By repeatedly counseling the public with these facts early on and coupling it to actionable ways for people to learn how to develop the ability to COVID-19 risk calculate (e.g. get vaccinated, wear masks in high-risk situations, outdoors are safer than indoors, surface transmission is not common) the rise of omicron and the looming ubiquity of infections would not seem so startling.

People are always going to engage in risky behavior some of us would never condone or partake in ourselves. Each person has a unique value hierarchy that they are going to juxtapose risks against — in pursuit of some values, some risks may be worth taking for individuals. Indeed, they are for me. The opportunity to integrate the lessons of harm reduction into the day-to-day life of the individuals traversing a world hospitable to a novel virus was missed. However, it is not too late to adopt this essential harm reduction framework given it will be something, for the foreseeable future, we will all use every day.

Amesh Adalja, M.D., is an infectious disease physician and a senior scholar at the Johns Hopkins Center for Health Security. Follow him on Twitter: @AmeshAA